A swollen tongue, a lung mass and a hole in the trachea
58 year old male walked into the emergency department with 3 hours history of swollen tongue and floor of the mouth. Patient was on second course of Clarithromycin by GP for probable chest infection. He had No stridor or wheeze. No skin manifestation. Chest x-ray showed a suspicious left hilar lung mass raising the possibility of paraneoplastic and nasal scope shows swollen epiglottis. The tongue swelling got worse in spite of the initial management needing urgent percutaneous tracheostomy.
Lack of familiarity of some of the team members with ACE-I induced angioedema created some doubting for the patient though not affecting course of management. Patient's past medical history includes well controlled asthma. Paitent was allergic to Penicillin and Aspirin and been on Ramipril for 5 years. He has been a smoker of 40 pack year.
Differential diagnosis included evolving anaphylaxis, ACE inhibitor-induced angioedema, angioedema secondary to acquired C1 esterase inhibitor deficiency. The actual diagnosis was found to be ACE inhibitor-induced angioedema with non-small cell lung carcinoma T4 N0 M0.
The case emphasied the approach to angioedema and when to consider a tracheostomy as well as the management of ACE-I induced angioedema, an area of much debate.
